Caroline Jehu-Appiah: Championing the Generation Equality Forum

Caroline Jehu-Appiah is the Deputy Director, Health, Nutrition and Eradication for Bill and Melinda Gates Foundation, based in the Nigeria Country Office. With over 25 years experience spanning public health, nutrition, human capital development, and program management across the health sector, she was also was largely responsible for advancing Universal Health Coverage, as well as the Lead Policy Advisor to the President on health, nutrition and human capital development. As one of the directors on Generation Equality Forum, she spoke with Chiemelie Ezeobi amongst other things, on the new report about ‘Women and the Impacts of COVID-19’, the essence of the Generation Equality Forum and what impact it is intended to have on women in developing economies

Can you tell us about the Generation Equality Forum and why it is so important for women in developing countries?

The Generation Equality Forum will be transformational for woman and girls across the world and in Africa in particular. This is to say we have not had a moment like this for gender equality in a quarter of a century and it comes at a very important time as women have been disproportionately affected by the pandemic.

So this forum is an opportunity for leaders around the world to commit and be held accountable. And it’s not just the right thing to do, it will also be critical for the world economic recovery from the pandemic and 2021 must be a year of action for gender equality. So the Generation Equality Forum is basically our opportunity to match the urgency of this moment and deliver for women and girls. And this is the first time that we have such a diverse range of participants, you know from the private sector to government, civil society that are coming together, to act on gender equality and the need for this basically stems from the evidence that we have today that the gender gap in global employment is widening.

And the current economic recovery rate is failing women and as male unemployment rates are falling female unemployment rates are still on the right, this is why it’s so important to act on this now and it’s so timely, given that the last gender conference was held almost a quarter of a century ago in Beijing.

How can Nigeria strengthen her Universal Health Coverage because we are really lagging behind in that regard?

There is a lot that needs to be done, and even though as you said, Nigeria is lagging in health outcomes and SDGs, a lot of progress have been made, progress in terms of under-five mortality, there have been some progress in terms of maternal mortality, access to family planning. There’s been some progress in routine Immunisation service, which has gone up. So I think, in a nutshell, we need to make progress in strengthening our health system as well. And also, especially for Nigeria, you know that, for the past 15 years the health sector has been grossly underfunded and in fact the COVID pandemic has been a wakeup call to show that Nigeria has been underfunding its health sector response. The budgetary allocation never exceeded six per cent.

So the COVID Pandemic has been an opportunity to shine the light on the fact that Nigeria needs to invest more in health because health costs money. And if you look across West Africa, Nigeria is hitting way below its peers, in terms of health sector allocation.

So it’s a combination of factors, it’s about making sure that health systems are strengthened , it is about staying the course on our programmatic responses around all our priority disease areas.

But the most important is funding to the health sector, because you know primary healthcare is the vehicle to achieving universal health coverage, yet we know that at the state level, the data that we have less than three per cent is allocated to primary health care any less is released.

You know, so the health sector, the state level really has very little to work with, so if one needs to ask, what the priority should be, I will say increasing funding for health and as I said COVID has been wake-up call.

What has been the impact on women and children?

Of course, the COVID pandemic has disproportionately affected women in terms of global employment not just locally and in Nigeria that gap in global employment is widening and the COVID recovery efforts are failing women more.

As male unemployment are falling, the data we have from the International Labour Organisation (ILO) and some of our partners, female unemployment is on the rise. When we started, we kind of assumed that recovery is slower for women but things are getting worse. This is why it is so important to get the commitment from the global leaders and civil society to commit and be held accountable to advance gender equality and ensure gender equality is put at the centre of the recovery efforts.

I am aware the BMGF released a report on gender and the pandemic, what are the highlights of this report?

Well, the highlights of the report are basically that women have been disproportionately affected. In terms of employment and also in terms of assess to family planning, you know during the lock down, a lot of women have not had the access to the various family planning commodities and option. The foundation is committed to bridging the gap in Family Planning support, globally and also for Nigeria. The highlight of the report prioritised Family Planning.

Are you targeting underserved communities or generally across the country?

We are working closely with teams on financial social protection, so the target of course, is the vulnerable woman and vulnerable household. Also in terms of our programmatic approach, every investment that the foundation is implementing in Nigeria there’s a deliberate and conscious effort to make it gender intentional and gender transformational.

So through our investments and everything that the foundation does, because our mission, as you know is to ensure everybody has a chance to lead a healthy and productive life and over the years we’ve invested over $ 50 billion towards this course, so we are now making a deliberate effort for the past three four years to put that into action.

Can you break it down , the figure you mentioned that was invested in what areas?

Well, the figure I’m quoting is the support the foundation has provided since its inception, for over 20 years and you know health is our biggest priority. We also have investments in agriculture, we have investments in water, sanitation and also education, those are the high level priority areas.

But at the foundation in Nigeria, focus is basically health and health, we have about six priority areas, so we invest in polio, as you well know, in routine Immunisation in maternal child health and family planning and in nutrition. Also in strengthening health systems and we also have investment in agriculture.

So at the country level those are the high priority areas and so far I think in Nigeria, the foundation has invested close to $1.6 billion, you know, since we started engaging with Nigeria.

With all these gaps, what do you think the government should be doing to improve on some of the identified lapses?

There is a lot that the government can do and just to highlight that some of the African countries have already made actionable and funded commitments ahead of the gender equality forum.

For example, President Kenyatta of Kenya increased funding to help tackle issues around gender violence. Other African countries have also stepped up to the task that would be South Africa, Kenya, Burkina Faso, Rwanda and Malawi, so what we expect from government is their commitment not just around policy advocacy but also financial commitment, because the difference between this forum and the Beijing Forum is that this time around, we are going to hold government accountable so it’s not just talking the talk and shedding the spotlight on issues around gender equality but it’s also to get governments to commit resources to move that agenda forward. And, as I said earlier, a number of African countries have already made policy and financial commitment, so it will be great if Nigeria could also do the same, because, as you know, issues around gender equality are a challenge in Nigeria and would need to be addressed when empowering woman.

Is there any plans to assess the impact of the report on women?

The difference, as I mentioned earlier, between this forum and the Beijing Forum that was held in 1995 is that issues around gender equality are going to be institutionalised.

So the plan is to have annual fora where profess and commitments to gender equality can be tracked so that is the good thing about this Generation Equality Forum, so it’s not just going to be a one off event but there’s going to be a cadence of meetings. And the plan is to have annual meetings to track progress track commitments towards the coalition teams or coalition actions of the GEF.

Sadly, malnutrition is still a big problem in Nigeria, so how will you use your wealth of experience to tackle that?

Yes, it is a very good question and very timely, as you rightly said, malnutrition issues are still around us still and it is quite prevalent especially in the north and we just kicked off a $15 million investment which is called Accelerating Maternal, Infant and Child Health Nutrition, so this is going to be one of our platform flagship where we will be working with six northern states including Lagos.

We are hoping this investment to be transformational. And we are going to work with existing partners, building on lessons from our previous investment to build a requisite capacity amongst the stakeholders, and we are going to target not just the supply side, that is not just the facilities, the community health workers, but also demand side, because a lot of issues around malnutrition are economic, they are behavioral.

So this is going to be a multi-pronged approach, because issues of malnutrition are multi factorial that a lot of bottlenecks that needs to be addressed like women’s education women’s economic capabilities. Also, nutritional knowledge as to what nutritious foods to give to children and also to build the capacity of our health care providers at the community level to counsel women and to use the existing platforms around anti-natal care and postnatal care because that is where we have to make sure that opportunities are not missed and hopefully we will be able to move the needle and see improvements in malnutrition in the next five to six years.

One of the major challenges concerning health in Nigeria is financial barrier to accessing health services, what do you think is the way out?

Well, there are a number of challenges or bottlenecks, I will like to categorise them as supply challenges so that would be health financing, as I said, Nigeria is allocating very little or not at all in line with the Abuja declaration of 15 per cent allocation. Nigeria has stagnated around six per cent for the past 10 to 12 years. There is the issue of infrastructure, Nigeria has over 30,000 health facilities and yet only 20 per cent of those are functional.

So the issues of infrastructure, the issues around human resources I mean, one can look at all the building blocks, you know human resources in terms of skill mix and capacity to deliver directory services. There is the issue of continuing medical education which is almost nonexistent, you know when all the nurses are graduated from school very few of them have had any a continuing medical education, training, there were the issues around supply chain and commodities.

As you know, the supply chain is very fragmented and broken and that’s what the foundation is also working to support, we have a number of investments on that. There’s also the issue of cost of health systems in general, issues around access to health care services, because in Nigeria, most of the services are funded out of pocket, in fact, close to 75 per cent of health services assessed by Nigerians are paid out of pocket and this is why there is the drive to scale up the implementation of the national health insurance scheme and at the state level state health insurance scheme.

There is the issue of service delivery, you know which ties in with human resources with the quality of care, capacity issues and then on the demand side people are not accessing health services as they should be and especially around COVID, as we all know, there was a disruption to essential healthcare services.

As I mentioned earlier, because healthcare is financed out of pocket, so the financial barrier to individuals that are living in poverty is a huge one. And of course issues around women empowerment, they don’t have the agency, especially in the north they need to seek permission from their husband to have to access health care and to deliver in health facility so all those issues compounds and have resulted in the situation that Nigeria has found itself.

The COVID crisis is an opportunity to do things differently, so Nigeria as a country should not waste the crisis and use it to rethink in terms of how to invest more in the health sector, because just one pandemic can bring the economy to a halt as we see. So it makes economic sense, not just from the health angle, but it makes economic sense for any country to invest in health because a health pandemic can disrupt the economy so the opportunities are there to make progress on that front.

So going forward what do we expect from the foundation?

The foundation is going to stay the course on its commitments, as I mentioned earlier our mission is to ensure everyone has equal opportunity to lead a healthy and productive life and as I said over the past 20 years we’ve invested over $50 billion, but then just to say that our resources are just a drop in the bucket compared to the total need.

So with all our interventions, given all our priority areas of focus which spans across maternal and child health, infectious diseases, research agenda we are going to stay the course and committed to supporting countries achieve the mission, which is to ensure that everyone has a chance to lead healthy and productive life.